HealthInfo Canterbury

Advance care planning (ACP)

Whakamaheretanga tiaki wawe

 

Advance care planning (ACP) is the process of thinking about, discussing and writing down your wishes about the type of medical care and treatment you want to receive in the future. In particular, towards the end of your life or when you can't make your own decisions.

It's a good idea to think about advance care planning before you become seriously ill or injured. It's especially important if you have a terminal condition, are very frail or have strong opinions about how and where you want to be treated at the end of your life.

A person creates an advance care plan while they're still able to decide what they want in the future.

If a person doesn't have an advance care plan and can't make decisions for themselves any more, their doctor (usually their GP) can create a medical care guidance plan for them.

My advance care plan

Your advance care plan records your preferences and wishes for health care at the end of your life. You should complete your advance care plan with the help of your GP, practice nurse or specialist team. It should be the result of your thoughts and discussions with your whānau/family and loved ones.

Your GP, practice nurse or specialist team can explain to you the details of medical treatments for the very ill or injured and talk you through the benefits and risks of these treatments. If you wish, they can lodge your advance care plan on your electronic health record, to be shared with other clinicians if and when it's needed. For example, if you're seriously injured or unwell and in hospital.

If you make a plan, it's very important that you give copies to your whānau/family and loved ones. You should also keep a copy somewhere that you and those who live with you know about. For example, with your enduring power of attorney, will and other important documents.

Your advance care plan will only be used if you aren't capable of making your own decisions and speaking for yourself.

Steps

You can do advance care planning a step at a time and at your own pace. The important steps are thinking about and talking about your wishes, writing them down and sharing them.

Step one – Think about it

Spend some time thinking about:

• what is important to you
• what gives your life meaning
• if there are any treatments or types of care that you would or wouldn't want
• who you would want to make decisions on your behalf if you weren't able to
• if there was a choice, how and where you would like to spend your last days
• what is important to you after your death.

Step two – Talk about it

The conversations you have with your whānau/family and loved ones about your advance care planning wishes are important. Think about who you would like to share your thoughts with. These people might include your:

• whānau/family
• enduring power of attorney
• friends and loved ones
• GP, practice nurse, hospital specialists and healthcare team
• spiritual advisor.

Step three – Write it down

You can download and print the My Advance Care Plan & Guide booklet or ask your general practice or specialist team for a copy. You can also order a print copy from Community & Public Health.

Use the My Advance Care Plan & Guide to write down what’s important to you, how you like to make decisions, what treatment you may or may not want and anything else you want others to be clear about.

If you're comfortable using a computer, you can also download an editable PDF that you can fill in electronically then print. To do this, you should save the PDF to your computer then open it with Adobe Reader. If you complete it in a web browser, your information will not be saved.

If you want to share your electronic plan, you should save a non-editable version. This video tells you how to do this.

You don't need to complete every section of the plan – just the parts you want to.

Once you've written down what’s important to you and what you want to happen, make an appointment with your GP, practice nurse or specialist team to discuss your advance care plan. Let them know that your appointment is for an advance care plan discussion. This will help to ensure that the appointment is long enough. It will also give them the chance to prepare before you arrive. Your advance care plan discussion might need more than one appointment.

You may have to pay for an appointment to discuss your advance care plan. Check with your general practice or specialist team.

Your GP, practice nurse or specialist team will go through your plan with you and help you complete section six (My treatment and care choices and My advance directives).

When your plan is finished and you're happy with it, you and the doctor, nurse or other healthcare professional who is helping you, will need to sign it. This confirms that you're competent to make these decisions. Competency is a legal term meaning that you can fully understand the decisions you're making. If you don't get a health professional to sign the form, other doctors might question your ability to make these decisions.

Step four – Share it

Once you've completed and signed your advance care plan, ask your GP, practice nurse or specialist team to enter your plan onto your electronic medical record. Then it will be available to your healthcare team if you go into hospital, see your doctor, or need help from the St John ambulance service.

Give a copy to:

• key whānau/family members
• your enduring power of attorney (if you have one)
• friends and loved ones.

Step five – Review it

Review your advance care plan regularly to make sure nothing has changed for you. If things change, update your plan.

It's important to share any changes with your GP and any people who have copies of your plan.

If you completed an advance care plan using the previous My Advance Care Plan document, it's still valid. If you lodged it on your electronic health record, it will still be there to be used by doctors or ambulance staff if and when it's needed.

If you decide to update your advance care plan, your GP, practice nurse or specialist team will help you put it into the new format.

  HealthInfo recommends the following pages

• Health Quality & Safety Commission New Zealand – Advance care planning (ACP)

  Information about advance care planning, including answers to some commonly asked questions, and videos of people talking about advance care planning

• Canterbury DHB – Deciding about CPR (resuscitation)

  Information about CPR, including what it is and who decides if you'll be given CPR.

• Age Concern – Enduring power of attorney information

  Information about enduring power of attorney.

  Pamphlets about enduring power of attorney are also available in Māori and Chinese on this page.

• Organ donation New Zealand

  Organ donation New Zealand has information that can help you decide if you want to become a donor and how you go about becoming a donor.

Written by the Canterbury DHB. Adapted by HealthInfo clinical advisers. Last reviewed June 2020.

ACP brochure adapted for use with permission of the Health Quality & Safety Commission 2018.

Page reference: 52246

Review key: HIDLT-326665